Provider Demographics
NPI:1457461956
Name:CALLESEN, MARK TRAVIS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:TRAVIS
Last Name:CALLESEN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4747 N 7TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-3653
Mailing Address - Country:US
Mailing Address - Phone:602-279-7655
Mailing Address - Fax:602-264-1806
Practice Address - Street 1:880 N COLORADO ST
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-3419
Practice Address - Country:US
Practice Address - Phone:480-820-0825
Practice Address - Fax:480-820-7863
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-08-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ230582084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ059536Medicaid
AZ059536Medicare ID - Type Unspecified